Based on a recent South Florida Business Journal Report, the five largest hospital operators in the region are Baptist Health South Florida, Tenet, HCA, Memorial Healthcare System and Jackson Memorial Hospital. See chart: Largest S. FL Hospital Operators. The top five all boasted net operating revenues in excess of $1 billion in fiscal year 2010. The top four all earned an excess of revenue over expenses (i.e. profits) in the 3-7% range. Jackson suffered a loss of $34.4 million versus $1.14 billion in revenue. SFBJ notes that Jackson's loss has narrowed by 80.7% when compared to 2009.

Meanwhile, U.S. News & World Report just released its Best Hospitals Report. To learn about their methodology, click HERE. This is the top five in South Florida according to USN&WR:

University of Miami, Jackson Memorial Hospital

Cleveland Clinic Florida

Mount Sinai Medical Center

Bascom Palmer Eye Institute (UM Health System)

Baptist Hospital of Miami

To their credit, some operators occupy both lists. After all, how can one continue to deliver top quality without also delivering strong financial results? Interestingly (and perhaps ominously), there are no for profit entities occupying the top five quality list.

According to Allan Baumgarten's Florida Health Market Review 2011, "Florida HMOs improved their net income in 2010, posting net income after taxes of $669.9 million, or 3.5% of underwriting revenues. That is up from 2009 results of $576.7 million, or 3.1% of premium revenues."

Baptist Health, South Florida has been named "one of the Most Wired healthcare organizations in the U.S." for the tenth time by Hospitals and Health Networks magazine.

According to a recent article in the Palm Beach Post, "Stimulus money set aside by Congress in 2009 is beginning to find its way to doctors and hospitals nationwide as they make the transition from paper medical records to electronic ones." (SEE ARTICLE In Fla., $248M of stimulus is planned to fuel a shift in medical records .)Meanwhile IOS Health Systems just announcedthat a physician in Puerto Rico has received her $18,000 Stimulus check and was the first in Puerto Rico do so. Read the press release, HERE.

New recommendations recently released by the FDA demonstrate the changing environment for conflicts of interest management and emphasize the need for pharmaceutical companies, medical device manufacturers and health care providers to ensure they have internal processes that adequately anticipate and meet the baseline requirements.

Last week, I receive a Groupon alert for a local restaurant I like. For those of you living under a rock, Groupon is a social networking group discount program.

Here's how it works. A local merchant, like a restaurant or hair salon, offers a discount - often 50% off or more. This gets a lot of attention. But, the discount isn't activated until a critical mass of Groupon subscribers 'tip" the deal. Enough people must commit to "paying" for the discount. That's how Groupon gets paid.

For the restaurant, the deal was $60 off. But, you had to pay Groupon $30 for the $60 off coupon. If you're good at math, you recognize the deal is really $30 off - still a nice discount. The deal didn't activate until it tipped with 20 people. Over 1,100 people ultimately took advantage of the deal. You now see the power of a rip-roaring discount. The restaurant will have to deliver. For all I know, they might "eat it" on this deal. But, if the restaurant's goal was to turn-on a large number of people to their restaurant to try it out - and potentially become repeat customers, this Groupon deal might be a smashing success.

Onward to healthcare. Some physicians and dentists have jumped in - offering Groupon discounts to subscribers for services. Their goal is the same as the restaurants. Think of the discount as a loss leader. Introduce the patient to the office. If they are happy with the service and care provided, perhaps they will become loyal, long-term paying patients.

Some doctors are already reporting eye-popping results. Over nine hundred new patients for a cosmetic procedure in California. Over a hundred new patients for dental work. Are these doctors losing money on the heavily discounted procedures? Difficult to tell. Will these people become long-term patients? Who knows?

Here's what we do know. Most medical and dental licensing boards have updated long-established policies that might create headaches for doctors embracing Groupon and other online daily deal discount websites as a marketing tool. A scant few are tackling the issues. Most are sitting on the sidelines. More on that in a minute.

Most licensing boards, if not all, have strict policies prohibiting fee-splitting. Fee splitting occurs when a patient is "induced' to visit a provider and the doctor "kicks back" a referral fee to the referrer. There are safe harbors which don't trigger enforcement of fee-splitting penalties - such as when a doctor refers to another doctor in his multi-specialty practice - and they are both employees in the same facility. If they split profits at the end of the year, then, in a sense, the referral has generated extra fees split by all. Fortunately, as a safe harbor, this does not trigger any action.

But, if two unrelated doctors have a handshake agreement whereby referrals will be paid a cool $300 for every surgery - that's likely against the law - and probably violates licensing board fee-splitting policies.

On its face, doctors who sponsor Groupon discount deals are cutting Groupon in on their professional fees for the referrals And, since there is no safe harbor for Groupon deals, a doctor could be on the wrong side of a Board investigation.

In the earlier example, it's easy to see how a doctor abuses the trust of his patient by getting paid for referring to a surgeon and receiving cash for the referral. The cash taints the doctor's judgment - and it puts the doctor's financial interest above the patient's interest. But, do payments to Groupon promote that same type of abuse? Doubtful.

With Groupon, the prospective patient is being given information and a discount. The patient is free to make their own decision as to whether or not to accept the advertised discount. There is no pre-existing doctor-patient relationship whereby misplaced trust can result in a bad outcome. The Groupon model is consumer directed healthcare in action.

The federal government has laws on its books which also prevent "kickbacks." The Office of Inspector General for U.S. Dept. Health and Human Services ("OIG") issued an Advisory Opinion on an analogous program - pay per lead - or pay per call program. There, OIG concluded that a pay per lead program did indeed violate the plain language of the Anti-Kickback Statute. And, such a program did not qualify for any statutory safe harbor. That said, OIG concluded they would not enforce the statute against participants in those programs, because such programs did not promote the type of abuse the statute was meant to curtail.

While this decision is helpful in giving a doctor comfort, a doctor making a decision whether or not to participate in Groupon must also pay attention to policies of their state professional licensing board. And, as noted, most licensing boards have explicit prohibitions against "fee splitting."

The Oregon Board of Chiropractic Examiners ("OBCE") appears to be the first out of the gate to tackle the issue. At a recent meeting, they formed a committee to draft language bringing their fee-splitting policy into the Internet age. Such language, if adopted, would narrowly allow doctor participation in Groupon like programs without opening the floodgates for other practices which abuse the doctor-patient relationship for personal financial gain.

It is unlikely professional licensing boards would take a strong stand against individual doctors for promoting Groupon deals. After all, the model voluntarily pushes down the cost of healthcare. But, Board investigations are often complaint-driven. So, if patients complain to the Board for any number of reasons, an investigation might broaden to include allegations of fee-splitting. Doctors who want to test the waters with social networking group discount programs would be well advised to proactively lobby their licensing bodies to update their decades-old fee-splitting policies. If a Board takes action against a doctor for fee-splitting, you can be sure that any assessed penalty would not be at a Groupon discount rate.

Jeffrey Segal, MD, JD, is founder and CEO of Medical Justice Services. Mike Sacopulos, JD, is general counsel for the organization. Run by physicians for physicians, Medical Justice is a membership-based organization that offers services and proprietary methods to protect physicians' most valuable assets - their practice and reputation. The company offers proactive services to deter frivolous medical malpractice lawsuits, prevent Internet defamation and provide strategies for successful counterclaim prosecution. Medical Justice works as a supplement to conventional professional liability insurance. www.MedicalJustice.com.